Impact of Maternal Body Mass Index on Intrapartum and Neonatal Outcomes in Brisbane, Australia, 2007 to 2013

The Impact of Maternal Obesity on Neonatal Outcomes of Pregnancies Complicated by Fetal Growth Restriction

OBJECTIVE

This study aimed to characterize the relationship between maternal obesity, fetal abdominal size, and neonatal morbidity in pregnancies complicated by fetal growth restriction (FGR).

STUDY DESIGN

Pregnancies complicated by FGR, which resulted in delivery of a live, singleton, nonanomalous infant at a single center between 2002 and 2013 were identified in a large, National Institutes of Health-funded database of detailed pregnancy and delivery information extracted by trained research nurses. Pregnancies complicated by diabetes were excluded. Fetal biometry measurements from third trimester ultrasounds performed at the same institution were extracted from another institutional database. Pregnancies were divided into cohorts based on fetal abdominal circumference (AC) gestational age percentile (<10th centile, 10-29th centile, 30-49th centile, and ≥50th centile) at the ultrasound closes to the date of delivery. Obesity was defined by prepregnancy body mass index >30 kg/m2. The primary outcome was a composite of neonatal morbidity (CM) including 5-minute Apgar < 7, arterial cord pH <7.0, sepsis, respiratory support, chest compressions, phototherapy, exchange transfusion, hypoglycemia requiring treatment, or neonatal death. Outcomes were compared between women with versus without prepregnancy obesity overall and then stratified by AC cohort.

RESULTS

A total of 379 pregnancies met criteria; CM occurred in 136 (36%). Overall, there was no difference in CM between infants born to women with versus without obesity (risk ratio (RR): 1.11, 95% confidence interval: 0.79-1.56). When stratified according to AC at ultrasound closest to delivery, there was higher prevalence of CM occurring among women with prepregnancy obesity than those without prepregnancy obesity when the fetal AC was >50th or 30 to 49th centile However, these differences did not reach statistical significance.

CONCLUSION

Our study identified no significant difference in risk of CM among growth-restricted infants of obese versus nonobese mothers, including among infants with very small AC. More research is needed to further examine the potential relationships postulated here.

KEY POINTS

· No significant differences in neonatal outcomes of FGR pregnancies in obese versus nonobese patients.. · No significant differences in AC percentile distribution in FGR pregnancies in obese versus nonobese.. · Pregnancies complicated by obesity had a higher need for cardiac support but not chest compressions..

Risk factors for a serious adverse outcome in neonates: a retrospective cohort study of vaginal births

OBJECTIVE

To investigate the hypothesis that risk factors in addition to an abnormal fetal heart rate pattern (aFHRp) are independently associated with adverse neonatal outcomes of labour.

DESIGN

Observational prospective cohort study.

SETTING

17 UK maternity units.

SAMPLE

585 291 pregnancies between 1988 and 2000 inclusive.

METHODS

Adjusted odds ratios (OR) with 95% confidence intervals (95% CI) were estimated from multivariable logistic regression.

MAIN OUTCOME MEASURES

Adverse neonatal outcome at term (5-minute Apgar score <7, and a composite measure comprising 5-minute Apgar score <7, resuscitation by intubation and/or perinatal death).

RESULTS

Analysis was based on 302 137 vaginal births at 37-42 weeks inclusive. We found a higher odds of Apgar score at 5 minutes <7 with suspected fetal growth restriction (OR 1.34, 95% CI 1.16-1.53), induction of labour (OR 1.41, 95% CI 1.25-1.58), nulliparity (OR 1.48, 95% CI 1.34-1.63), booking body mass index ≥30 (OR 1.18, 95% CI 1.02-1.37), maternal age <25 (OR 1.23, 95% CI 1.10-1.39), black ethnicity (OR 1.21, 95% CI 1.03-1.43), early-term birth at 37-38 weeks (OR 1.13, 95% CI 1.02-1.25), late-term birth at 41-42 weeks (OR 1.14, 95% CI 1.01-1.28), use of oxytocin (OR 1.27, 95% CI 1.14-1.41), maternal pyrexia (OR 1.87, 95% CI 1.46-2.40), aFHRp and presence of meconium (aFHRp without meconium: OR 2.40, 95% CI 2.15-2.69; meconium without aFHRp: OR 2.20, 195% CI.94-2.49; both aFHRp and meconium: OR 4.26, 95% CI 3.74-4.87). The results were similar when the composite adverse outcome was considered.

CONCLUSIONS

A range of risk factors, including suspicion of fetal growth restriction, maternal pyrexia and presence of meconium, are implicated in poor birth outcomes in addition to aFHRp. Interpretation of the fetal heart rate pattern alone is insufficient as a basis for decisions about escalation and intervention.

Patterns of Labour Interventions and Associated Maternal Biopsychosocial Factors in Australia: a Path Analysis

In Australia, nearly half of births involve labour interventions. Prior research in this area has relied on cross-sectional and administrative health data and has not considered biopsychosocial factors. The current study examined direct and indirect associations between biopsychosocial factors and labour interventions using 19 years of population-based prospective data. The study included singleton babies among primiparous women of the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health. Data from 5459 women who started labour were analysed using path analysis. 42.2% of babies were born without intervention (episiotomy, instrumental, or caesarean delivery): Thirty-seven percent reported vaginal birth with episiotomy and instrumental birth interventions, 18% reported an unplanned caesarean section without episiotomy and/or instrumental interventions, and 3% reported unplanned caesarean section after episiotomy and/or instrumental interventions. Vaginal births with episiotomy and/or instrumental interventions were more likely among women with chronic hypertension (RRR(95%-CI):1.50(1.12-2.01)), a perceived length of labour of more than 36 h (RRR(95%-CI):1.86(1.45-2.39)), private health insurance (RRR(95%-CI):1.61(1.41-1.85)) and induced labour (RRR(95%-CI):1.69(1.46-1.94)). Risk factors of unplanned caesarean section without episiotomy and/or instrumental birth intervention included being overweight (RRR(95%-CI):1.30(1.07-1.58)) or obese prepregnancy (RRR(95%-CI):1.63(1.28-2.08)), aged ≥ 35 years (RRR(95%-CI):1.87(1.46-2.41)), having short stature (< 154 cm) (RRR(95%-CI):1.68(1.16-2.42)), a perceived length of labour of more than 36 h (RRR(95%-CI):3.26(2.50-4.24)), private health insurance (RRR(95%-CI):1.38(1.17-1.64)), and induced labour (RRR(95%-CI):2.56(2.16-3.05)). Prevention and management of hypertension, diabetes, and obesity during preconception and/or antenatal care are keys for reducing labour interventions and strengthening the evidence-base around delivery of best practice obstetric care.

No impact of gestational diabetes mellitus on pregnancy complications in women with PCOS, regardless of GDM criteria used

Polycystic ovary syndrome (PCOS) is characterized by the presence of insulin resistance, and women with PCOS have high prevalence of gestational diabetes (GDM). Both conditions have been associated with increased risk for pregnancy complications such as preterm birth, preeclampsia and increased offspring birth weight. We aimed to estimate the prevalence of GDM in women with PCOS using both previous and new diagnostic criteria, and to analyse whether the risk of pregnancy complications increased with the presence of GDM. In addition, we aimed to assess the response to metformin treatment in PCOS women with GDM. We performed post-hoc analysis of three prospective, double blinded studies of altogether 791 pregnant women with PCOS randomized to either metformin or placebo treatment from first trimester to delivery. Glucose data allowing GDM classification after previous (WHO 1999) and new (WHO 2013 and Norwegian 2017) diagnostic criteria were available for 722 of the women. Complications such as preeclampsia, late miscarriage and preterm birth, birth weight and gestational age were correlated to the presence of GDM and metformin treatment. The prevalence of GDM was 28.3% (WHO 1999), 41.2% (WHO 2013) and 27.2% (Norwegian 2017). Having GDM already in first trimester associated with increased risk for late miscarriage (p<0.01). Having GDM according to newer criteria correlated to increased maternal age and BMI (p<0.001). Otherwise, having GDM (any criteria) correlated neither to the development of preeclampsia, nor to birth weight z-score or the proportion of offspring being large for gestational weight. Maternal age and BMI, parity and gestational weight gain, but not GDM or metformin treatment, were determinants for birth weight z-score. Conclusion: in pregnant women with PCOS, having GDM did not increase the risk for other pregnancy complications except for an increased risk for late miscarriage among those with GDM already in the first trimester.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Neonatal outcomes in obese pregnant women who develop preeclampsia

OBJECTIVE

Obesity and preeclampsia in pregnant women are each independently associated with poorer neonatal outcomes. We study obesity and preeclampsia alone and also in combination in pregnant women to determine their association with neonatal outcomes.

STUDY DESIGN

This retrospective study (n = 664) compared four groups: 1) no preeclampsia/no obesity, 2) no preeclampsia/yes obesity, 3) yes preeclampsia/no obesity, and 4) yes preeclampsia/yes obesity. The primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes were low birth weight, low Apgar 1 score, and low Apgar 5 score.

RESULTS

Those with yes preeclampsia/yes obesity (OR:3.06, 95% CI:1.76, 5.32, p < 0.001) and those with yes preeclampsia/no obesity (OR:1.98, 95% CI:1.03, 3.80, p < 0.05) each had significantly higher odds for NICU admission. Those with no preeclampsia/yes obesity were not associated with NICU admission. Yes preeclampsia/yes obesity did not have any significant association with low birth weight, low Apgar 1 score, and low Apgar 5 score.

CONCLUSION

Patients with preeclampsia alone or preeclampsia/obesity combined are associated with higher odds for NICU admission. However, obesity alone without preeclampsia is not associated with NICU admission. This knowledge can allow the Pediatric service prior to delivery to prepare and mitigate potential poor neonatal complications.

Influence of a Water-Based Exercise Program in the Rate of Spontaneous Birth: A Randomized Clinical Trial

Introduction: Many women change their lifestyles and habits when they become pregnant, to avoid potentially harmful effects to themselves and their babies. This is especially so with respect to physical exercise, which is often greatly reduced due to ignorance of the benefits it provides during pregnancy. Aim: To evaluate the prevalence of spontaneous birth among women who participated in a water-based physical exercise program. Methods: A randomized clinical trial was conducted with a sample of 129 pregnant women (Control Group, CG = 64; Exercise Group, EG = 65). A physical exercise protocol, specifically designed for pregnant women, was created and applied. Those in the EG performed 60 min exercise sessions, three times per week for 17 weeks. The participants in the CG received routine check-ups and advice throughout their pregnancy. Findings: The women in the EG presented better results for the onset of spontaneous birth (OR = 2.060 (0.980–4.332)) and for neonate Apgar score of 10 at five minutes (OR = 8.53 (3.60–20.17)). Those who had normal weight at the start of pregnancy achieved better results for spontaneous delivery (OR = 2.099 (1.017–4.335)) than those with overweight/obesity. The rate of caesarean delivery was higher in the women with overweight/obesity (OR = 3.570 ((1.226–10.397)) than in those with normal weight. Conclusions: In our study, the women who followed the water-based exercise program gained less weight during pregnancy, which facilitated a better rate of spontaneous, non-instrumental childbirth, together with a better Apgar test score at five minutes.

Maternal body mass index and pregnancy outcomes: a systematic review and metaanalysis

OBJECTIVE DATA

The purpose of this study was to determine the effect of body mass index category on pregnancy outcomes.

STUDY

Five databases (Medline, Embase, PubMed, www.clinicaltrials.gov, and Cochrane) were searched from inception until February 2019 for English or French publications that reported on pregnancy outcomes in women with body mass index ≥30 kg/m². Reference lists of included articles were searched, and authors were contacted for missing data where necessary. Because no randomized trials were identified, we included single-center and population-based cohort studies that stratified pregnancy outcomes under the following body mass index categories: underweight, standard weight, overweight, and obese classes I-III, based on the World Health Organization international classification system.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was appraised with the use of the Newcastle-Ottawa Scale Quality Assessment Scale for cohort studies. Because significant heterogeneity was anticipated among studies, we used random-effects metaanalysis to arrive at pooled estimates and 95% confidence intervals for pregnancy outcomes in each body mass index category and relative risks in relation to women with a standard body mass index.

RESULTS

We identified 10,258 studies, of which 13 studies with a low risk-of-bias that described 3,722,477 pregnancies that were included in the metaanalysis. Most adverse pregnancy outcomes increased steadily with increasing body mass index category. Compared with women with body mass index 18.5-24.9 kg/m², women with body mass index >40 kg/m² were at increased risk for gestational diabetes mellitus [17% vs 3.9%; relative risk, 4.6 [95% confidence interval, 3.6-5.9]), hypertensive disorders of pregnancy (15.9% vs 3.5%; relative risk, 4.6 [95% confidence interval, 3.4-6.0]), and cesarean delivery (47.7% vs 26.0%; relative risk, 1.86 [95% confidence interval, 1.75-1.97]). Babies were at increased risk for hypoglycemia (4.1% vs 1.4%; relative risk, 3.3 [95% confidence interval, 2.8-3.8]), macrosomia (12.9% vs 6.2%; relative risk, 2.6 [95% confidence interval, 1.4-4.7]), infection (2.8% vs 1.3%; relative risk, 2.3 [95% confidence interval, 1.6-3.3]), birth trauma (1.3% vs 0.9%; relative risk, 2.1 [95% confidence interval, 1.2-3.8]), respiratory distress (5.1% vs 2.7%; relative risk, 2.0 [95% confidence interval, 1.8-2.2]), death (1.4% vs 0.9%; relative risk, 1.8 [95% confidence interval, 1.2-2.9]), and neonatal intensive care unit admission (13.5% vs 9.5%; relative risk, 1.6 [95% confidence interval, 1.4-1.9]).

CONCLUSION

There is a linear association between maternal body mass index and almost all adverse pregnancy outcomes. These risks, stratified by body mass index category as presented in this article, would facilitate counselling and encourage appropriate interventions to improve outcomes for mothers and babies.

Effects of physical exercise during pregnancy on maternal and infant outcomes in overweight and obese pregnant women: A meta-analysis

BACKGROUND

Overweight and obesity are related to maternal and infant physical health, such as gestational diabetes, preeclampsia, and macrosomia. The purpose of this meta-analysis was to assess the effect of physical exercise on maternal and infant outcomes in overweight and obese pregnant women.

METHODS

Two researchers independently searched Cochrane Library, Embase, PubMed, Web of Science, and ClinicalTrials.gov. for English-language articles based on randomized controlled trials examining physical exercise in overweight and obese pregnant women and its effect on maternal and infant outcomes. Primary outcomes were gestational weight gain and a relative risk of gestational diabetes. Secondary outcomes were gestational hypertension, preeclampsia, cesarean delivery, birthweight, large for gestational age, small for gestational age, macrosomia, and preterm birth. Risk bias was evaluated by Cochrane Collaboration's tool. The results of integration were reported as relative risks (RR), mean difference, or standard mean difference with 95% confidence intervals (CI). This meta-analysis was registered on PROSPERO on November 18, 2017, with registration number CRD42017081565.

RESULTS

Thirteen studies involving 1439 participants were included. Physical exercise reduced gestational weight gain (mean difference = -1.14 kg, 95% CI = [-1.67 to -0.62], P < 0.0001) and the risk of gestational diabetes (RR = 0.71, 95% CI = [0.57-0.89], P = 0.004) in overweight and obese pregnant women. There were no significant differences in other outcomes such as gestational hypertension, preeclampsia, cesarean delivery, birthweight, large for gestational age, small for gestational age, macrosomia, and preterm birth.

CONCLUSIONS

Prenatal exercise interventions reduced gestational weight gain and the risk of gestational diabetes for overweight and obese pregnant women, which reinforced the benefits of exercise during pregnancy. However, no evidence was found with respect to benefits and/or harm for infants. Consideration should be taken when interpreting these findings as a result of the relative small sample size in this meta-analysis. Further larger well-designed randomized trials may be helpful to assess the short-term and long-term effects of prenatal exercise on maternal and infant outcomes.

Adverse Neonatal Outcomes in Overweight and Obese Adolescents Compared with Normal Weight Adolescents and Low Risk Adults

STUDY OBJECTIVE

To evaluate the association between maternal body mass index and neonatal outcomes in adolescents and to compare neonatal outcomes between overweight and obese adolescents and obstetric low-risk adult women.

DESIGN

Retrospective cohort study using data from the Swedish Medical Birth Register.

SETTING

Sweden.

PARTICIPANTS

All 31,386 primiparous adolescents younger than 20 years of age and 178,844 "standard" women, defined as normal weight, obstetric low-risk adult women who delivered between 1992 and 2013. The adolescents were categorized according to weight and height in early pregnancy into body mass index groups according to the World Health Organization classification. Logistic regression models were used.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Neonatal outcomes in relation to maternal body mass index groups.

RESULTS

In the adolescents, 6109/31,386 (19.5%) and 2287/31,386 (7.3%) were overweight and obese, respectively. Compared with normal weight adolescents, overweight adolescents had a lower risk of having small for gestational age neonates, and higher risks for having neonates with macrosomia, and being large for gestational age and with Apgar score less than 7 at 5 minutes. The obese adolescents had increased risk for having neonates being large for gestational age (3.8% vs 1.3%; adjusted odds ratio [aOR], 2.97 [95% confidence interval (CI), 2.30-3.84]), with macrosomia (>4500 g) (4.6% vs 1.4%; aOR, 2.95 [95% CI, 2.33-3.73]), and with Apgar score less than 7 at 5 minutes (2.2% vs 1.1%; aOR, 1.98 [95% CI, 1.43-2.76]) than normal weight adolescents. Compared with the standard women, overweight and obese adolescents had overall more adverse neonatal outcomes.

CONCLUSION

Overweight and obese adolescents had predominantly increased risks for adverse neonatal outcomes compared with normal weight adolescents and standard women.

Maternal age and body mass index at term: Risk factors for requiring an induced labour for a late-term pregnancy

INTRODUCTION

We investigated the role of body mass index (BMI) and maternal age on the risk of late-term induction, prolonged induction time and caesarean section (CS) after induction.

MATERIAL AND METHODS

This is a retrospective, observational study. All women without any fetal or maternal pathological condition, uterine scars or any other indication for an elective caesarean birth and had a singleton foetus in the cephalic position at term were included.

RESULTS

A total of 4006 women had a spontaneous onset of labour and 612 were induced for a late-term pregnancy. Labour induction was significantly more common in overweight (Adj Odds Ratio (OR) 1.48 95%CI 1.22-1.78) and obese (Adj OR 1.63 95%CI 1.24-2.14) women. Among induced women, a BMI ≥ 30 was a risk factor for a prolonged induction time in both nulliparous (AdjOR 2.4, 95%CI 1.02-5.67) and multiparous women (AdjOR 4.24, 95%CI 1.02-17.6). A BMI > 25-29.9 was significantly associated with a prolonged induction time only in nulliparous women (AdjOR 1.86 95%CI 1.05-3.30). A CS was more frequent in overweight (AdjOR 1.74, 95% CI 1.052.89) and obese women (AdjOR 2.72, 95%CI 1.42-5.25). Nulliparous women ageed 30-34 years had an induction time longer than women <30 years (OR 2.04 95%CI 1.07-3.91).

CONCLUSIONS

The results of this study suggest that a BMI > 25 kg/m2 at term of pregnancy is a risk factor for the induction of labour during a late-term pregnancy, a prolonged induction time and higher caesarean section rate.

Maternal demographic and intrapartum antecedents of severe neonatal outcomes at term

Objective: To determine key demographic and intrapartum antecedents predisposing to severe adverse neonatal outcome at term.Methods: This was a retrospective cohort study of severe adverse neonatal outcomes of nonanomalous singleton term births at an Australian tertiary maternity unit between January 2007 and April 2017. Serious neonatal outcome (SNO) was defined as any of the following: Apgar score ≤3 at 5 min, severe respiratory distress syndrome, severe acidosis, admission into neonatal intensive care unit (NICU), stillbirth, or neonatal death. Multivariable generalized estimating equations were used to identify key demographic and intrapartum risk factors predisposing to poor neonatal outcomes.Results: There were 77 888 births with SNO occurring in 7247 (9.3%) cases. Young maternal age, raised BMI, indigenous ethnicity, nulliparity, smoking, illicit drug use, and diabetes mellitus were more common in the SANO cohort. Instrumental birth (aOR 3.24, 95%CI 3.02-3.47, p < .001), emergency cesarean section (aOR 1.61, 95%CI 1.49-1.73, p < .001), emergency cesarean for nonreassuring fetal status (aOR 3.45, 95%CI 3.04-3.92, p < .001), cord accidents (aOR 4.98, 95%CI 2.81-8.83, p < .001) and intrapartum hemorrhage (aOR 1.42, 95%CI 1.08-1.87, p = .01) were major antecedents. Induction of labor (aOR 1.08, 95%CI 1.01-1.15, p = .03), prolonged second stage (aOR 1.76, 95%CI 1.55-2.00, p < .001) and use of intramuscular opioids/narcotics (aOR 1.41, 95%CI 1.30-1.52, p < .001) were also associated with adverse neonatal outcome. Low birth weight (< 5th and <10th centiles) and macrosomia (> 90th and >95th centiles) and delivery at 37 weeks and >41 weeks were additional risk factors.Conclusion: There are multiple maternal and intrapartum risk factors which can predispose to severe outcomes in the neonate.

Effect of pre-pregnancy body mass index on respiratory-related neonatal outcomes in women undergoing elective cesarean prior to 39 weeks

Objective To examine the association between pre-pregnancy body mass index (BMI) and neonatal respiratory-related outcomes among women who underwent an elective cesarean section (CS). Methods A retrospective cohort study was conducted using the Centers for Disease Control and Prevention (CDC)'s 2009-2013 period linked birth/infant death dataset. Women who had elective CSs at term were categorized by their pre-pregnancy BMI as normal, overweight, obese or morbidly obese. Odds ratios (OR) and 95% confidence intervals (CIs), adjusted for baseline characteristics, were calculated using multivariate logistic regression to estimate the neonatal risks in relation to maternal pre-pregnancy BMI. Results Our cohort consisted of 717,080 women, of whom 39.9% had normal BMI, 27.0% were overweight, 25.7% obese and 7.4% morbidly obese. A dose-dependent relationship between maternal pre-pregnancy BMI and assisted ventilation was seen. Furthermore, infants born to morbidly obese women were at significantly increased risk for assisted ventilation over 6 h (OR 1.24, 95% CI 1.15-1.35) and admission to intensive care units (OR 1.17, 95% CI 1.13-1.21). Infant mortality rates were 4.2/1000 births for normal weight women, and 5.5/1000 births among the morbidly obese group (OR 1.43, 95% CI 1.25-1.64). Risk for adverse outcomes was increased with elective SC performed at earlier gestational age, and this effect was not modified by use of corticosteroids. Conclusion Overweight and obese women are at particularly greater risk of adverse newborn outcomes when elective CSs are done before 39 weeks. In these women, elective CSs should be delayed until 39 weeks, as corticosteroid use did not eliminate this association.

Maternal demographic factors associated with emergency caesarean section for non-reassuring foetal status

OBJECTIVES

This study aimed to determine maternal and obstetric factors associated with emergency caesarean section (CS) for non-reassuring foetal status (NRFS).

MATERIALS AND METHODS

This was a retrospective analysis of term singleton births between January 2007 and December 2015 at the Mater Mother's Hospital in Brisbane. The study group comprised all cases of emergency CS for NRFS, and the control cohort comprised all other births meeting the inclusion criteria but excluding those in the study cohort.

RESULTS

Over the study period, there were 74,177 births fulfilling the inclusion criteria. The overall rate of emergency CS for NRFS was 4.2% (3132/74,177). Multivariate analysis showed that being overweight and obese, Indian and "other" ethnicity, artificial reproductive techniques, smoking, induction of labour and gestation at 39-42 weeks were associated with an increased risk, whereas being underweight, female sex, hypertension and birth without labour conferred a lower risk.

CONCLUSION

Many maternal and obstetric factors were associated with emergency CS for NRFS and influenced adverse perinatal outcomes. Recognition of these risk factors could help risk stratify women prior to labour.

The intrapartum and perinatal risks of sleep-disordered breathing in pregnancy: a systematic review and metaanalysis

OBJECTIVE DATA

Sleep-disordered breathing is an increasingly common condition in nonobstetric populations and is associated with significant morbidity. The incidence of sleep-disordered breathing in pregnancy is unknown, and it is likely that many cases go undiagnosed.

STUDY

A systematic review and metaanalysis was undertaken to determine whether pregnant women who receive a diagnosis of sleep-disordered breathing are more likely to have adverse intrapartum and perinatal outcomes compared with control subjects.

STUDY APPRAISAL AND SYNTHESIS METHODS

PubMed, Embase, and Cinahl databases were searched for full-text publications in English of sleep-disordered breathing and human pregnancy up to June 2017. Only studies that reported on sleep-disordered breathing in relation to gestational age or birthweight at delivery, preterm birth, mode of delivery, cord pH, Apgar score, nursery admission, stillbirth or perinatal death, meconium at delivery, or wound complications were included.

RESULTS

A total of 1576 results were identified; 33 studies met inclusion criteria. Women with sleep-disordered breathing were older (mean difference, 1.66; 95% confidence interval, 1.04-2.28) and had a higher body mass index (mean difference, 3.31; 95% confidence interval, 2.30-4.32) than those who did not. Maternal sleep-disordered breathing was associated significantly with preterm birth (<37 weeks gestation; odds ratio, 1.86; 95% confidence interval, 1.50-2.31) and low birthweight (<2500 g; odds ratio, 1.67; 95% confidence interval, 1.00-2.78). These women were also less likely to have a vaginal delivery (odds ratio, 0.61; 95% confidence interval, 0.48-0.78) and to be at a higher risk of having an assisted vaginal delivery (odds ratio, 1.88; 95% confidence interval, 1.10-3.21) or a cesarean delivery (odds ratio, 1.81; 95% confidence interval, 1.55-2.11). The risk of both elective (odds ratio, 1.38; 95% confidence interval, 1.09 - 1.76) and emergency cesarean (odds ratio, 2.52; 95% confidence interval, 1.20-5.29) was increased. In addition, women with sleep-disordered breathing were at a higher risk of having an infant with a 5-minute Apgar score <7 (odds ratio, 2.14; 95% confidence interval, 1.24-3.71), stillbirth or perinatal death (odds ratio, 2.02; 95% confidence interval, 1.25-3.28), and neonatal nursery admission (odds ratio, 1.90; 95% confidence interval, 1.38-2.61).

CONCLUSION

Maternal sleep-disordered breathing is associated with increased risks of adverse intrapartum and perinatal outcomes.

Perinatal risk factors for low and moderate five-minute Apgar scores at term

OBJECTIVE

To evaluate the specific maternal and perinatal variables associated with a low (≤3) or moderate (4-6) Apgar score, compared to a high (≥7) score.

STUDY DESIGN

This was a retrospective, cohort study of 58429 term singleton babies born at the Mater Mother's Hospital in Brisbane, Australia in 2007-2013. Maternal demographics, socio-economic status using the Australian Socioeconomic Index for Areas (SEIFA) score, obstetric factors, and birth outcomes were compared for neonates grouped into three categories based on their five-minute Apgar: low (≤3), moderate (4-6) and high (≥7). The low- and moderate-score cohorts were individually compared to the high-score cohort using both univariate and multivariate analysis.

RESULTS

Logistic regression analysis confirmed that of the variables analysed, only maternal public insurance status (OR 2.1, 95% CI 1.5-3.1), breech presentation (OR 2.4, 95% CI 1.1-4.6), other non-cephalic presentation (OR 9.5, 95% CI 2.2-25.4), intramuscular narcotic use (OR 2.3, 95% CI 1.5-3.5), and presence of meconium (OR 3.7, 95% CI 2.5-5.4) were significantly associated with low Apgar scores. Variables significantly associated with a moderate score were: SEIFA ≤50th centile (OR 1.6, 95% CI 1.2-2.0) and 61st to 70th centile (OR 1.31, 95% CI 0.9-1.8) categories, maternal public insurance status (OR 2.7, 95% CI 2.2-3.3), nulliparity (OR 2.0, 95% CI 1.7-2.5), emergency caesarean birth (OR 2.6, 95% CI 2.1-3.2), instrumental birth (OR 2.3, 95% CI 1.9-2.9), and presence of meconium (OR 2.6, 95% CI 2.1-3.2).

CONCLUSIONS

Factors associated with low and moderate Apgar scores vary in type and degree of influence. Distinctions in the perinatal background can help predict newborn compromise and accelerate delivery of care.